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. 2013 Mar 28;2013(3):CD008088.
doi: 10.1002/14651858.CD008088.pub3.

Anti-TNF-α treatment for pelvic pain associated with endometriosis

Donghao Lu  1 , Huan Song, Gang Shi
Affiliations

Anti-TNF-α treatment for pelvic pain associated with endometriosis

Donghao Lu et al. Cochrane Database Syst Rev. .

Abstract

Background: Endometriosis is a chronic, recurring condition that can develop during the reproductive years. It is characterised by the development of endometrial tissue outside the uterine cavity. It is the most common cause of pelvic pain in women. This endometrial tissue development is dependent on oestrogen produced primarily by the ovaries and, therefore, traditional management has focused on suppression of ovarian function. Mounting evidence shows that altered immune function plays a crucial role in the genesis and development of endometriosis. In this review we considered modulation of the inflammation as an alternative approach.

Objectives: To determine the effectiveness and safety of anti-tumour necrosis factor-α (anti-TNF-α) treatment in the management of endometriosis in premenopausal women.

Search methods: For the first publication of this review, we searched for trials in the following databases (from their inception to August 2009): Cochrane Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, CINAHL, and PsycINFO. In addition, we searched all reference lists of included trials and contacted experts in the field in an attempt to locate trials. We reran this search to 3 September 2012 for this update.

Selection criteria: Randomised controlled trials (RCTs) comparing anti-TNF-α drugs with placebo, no treatment, medical treatment, or surgery for pelvic pain associated with endometriosis were included.

Data collection and analysis: Two review authors independently selected trials for inclusion, assessed trial quality, and extracted data using data extraction forms. The domains assessed for risk of bias were sequence generation, allocation concealment, blinding, incomplete outcome data, and selective outcome reporting. We used risk ratios (RR) for reporting dichotomous data with 95% confidence intervals (CI), whilst we expressed continuous data as mean differences (MD). We assessed statistical heterogeneity using the I(2) statistic.

Main results: Only one trial involving 21 participants was included. The results showed no evidence of an effect of infliximab, one of the known anti-TNF-α drugs, on pelvic pain reduction using the Biberoglu-Behrman (BB) score (0 to 3 scale) for participants (MD -0.14, 95% CI -0.43 to 0.15), the BB score for clinicians (MD -0.14, 95% CI -0.39 to 0.11), or a visual analogue pain score (VAS, 100 mm scale) (MD -5.60, 95% CI -16.10 to 4.90), or on the use of pain killers (ibuprofen, g/day) (MD -0.10, 95% CI -0.30 to 0.10). There was no evidence of an increase in adverse events in the infliximab group compared with placebo (RR 3.73, 95% CI 0.22 to 63.66). We found no evidence of clinical benefits of infliximab for endometriotic lesions, dysmenorrhoea, dyspareunia, or pelvic tenderness. To date, there is no trial that has reported a cost-effectiveness analysis of anti-TNF-α drugs, or the odds of recurrence.

Authors' conclusions: This review was updated in 2012. The results of the original review published in 2010 remain unchanged. There is still not enough evidence to support the use of anti-TNF-α drugs in the management of women with endometriosis for the relief of pelvic pain.

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Conflict of interest statement

The authors declare that all the analysis and interpretation reflected the opinions of the authors; no conflict of interest was involved in the analysis or interpretation of data, or in the writing of the systematic review.

Figures

1
1
Study flow diagram.
2
2
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
3
3
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
4
4
Forest plot of comparison: 1 Infliximab versus placebo, outcome: 1.1 Relief of pelvic pain.
5
5
Forest plot of comparison: 1 Infliximab versus placebo, outcome: 1.2 Adverse events.
1.1
1.1. Analysis
Comparison 1 Infliximab versus placebo, Outcome 1 Relief of pelvic pain.
1.2
1.2. Analysis
Comparison 1 Infliximab versus placebo, Outcome 2 Adverse events.
1.3
1.3. Analysis
Comparison 1 Infliximab versus placebo, Outcome 3 Improvement in endometriotic lesions.
1.4
1.4. Analysis
Comparison 1 Infliximab versus placebo, Outcome 4 Improvement of endometriosis‐related symptoms ‐ dysmenorrhoea.
1.5
1.5. Analysis
Comparison 1 Infliximab versus placebo, Outcome 5 Improvement of endometriosis‐related symptoms ‐ dyspareunia.
1.6
1.6. Analysis
Comparison 1 Infliximab versus placebo, Outcome 6 Improvement of endometriosis‐related symptoms ‐ pelvic tenderness.
See this image and copyright information in PMC

Update of

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